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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> To: San Joaquin County JOB# c 3 067 - 3 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2 <br /> T T &n jo oma. L/� �/�m VALID r` a t2- Th Z j z DRIVEWAYS: <br /> (Applicant Name) STREETL1oQn}rz�.�J <br /> AREA ?rfo(1,tTi'x�,V QUAD ,U� <br /> >� TYPE $E�L <br /> (M 'li g Address) FORMS 5� G-�1 U, 12-2-'5 <br /> NOTES <br /> (City, Stat ,Zip Code) <br /> 02L)q z4 -)L1 - qL) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the i c,3�t side of o 1 �i sic 6r- ap roximately�i7' �S- ee ile l.S <br /> of yt3 SI L. % by performing the following work(description of work): <br /> 16 <br /> ,�c�fzr�tCv lh cru cl -P Q vcom t0a± `- 2=(d-,e 5e�virp . <br /> Work will commence on or about / v for approximately days. <br /> I,the undersigned, certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> EPUS SVWH'I,IASTER.PS ENCROACHUENTPERMIT APPLVT'.ON DOC (01:08) <br />